Can my doctor’s office charge me for lab work that they sent out to the lab?

I recently took over a medical billing company and work 100% from home now. I'm currently working off an HP intel i5 laptop docked to a larger monitor. Looking to purchase a desktop for more long-term/harder use. My current laptop is 12GB RAM, 512 SSD. 90% of what I'm working with is online, but I usually have, at minimum, 20 internet browser windows open, and my laptop just gets bogged down and sounds angry. Budget hoping to be $1000 or less. I'm thinking I need to up it to at least 16GB RAM, but I'll be honest, I don't know enough about the spec side of things. Help!

Considering the following:

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Is it normal to have a double amount for the same accession?

Hi !

1. To set the stage, I was on Cobra until its end date in Nov 2023. However, I discovered in Sept 2023 that the insurance company themselves thought I was not active. I eventually got it rectified to show me active under the insurance company
2. Fast forward to current time, I just got surprised by a dental bill from a July 2023 service - and the bill was not processed through my insurance - since my insurance thought i was not active as explained in part 1
3. My dental office will not refile again since its been over a year since the dental services were rendered - claiming my insurance will just throw out the claim again
4. Currently - i'm looking at my insurance web portal - and I dont see any file on the July 2023 dental services - that i can bring up with an insurance agent

Will the insurance company have record of at least bouncing the 2023 dental claim ?

Wondering any tips before i try to call insurance company and get this sorted out ?

Any advice helps, thank you !

Trying to file facility claim on Availty. Payer is Carelon Behavioral Health.

After entering first few fields system kicks me out.

Anyone else?

I work for a billing office for a virtual group. Two of the doctors in this group recently decided to open wound care clinics. Obviously this is one of the more challenging specialties. Our coders are doing a phenomenal job, but they are definitely still dealing with a much higher rate of denials than our PT offices. If anyone here is a wound care guru I would love to pick your brain.

Has anyone recently took the compliance coding test with AAPC that might be able to give me some tips on how to pass since there isnt any books for it only reference sheets on the split screen of the exam. I already took the practice test and had some issues with search bar and reference sheets. I take my test in 11 days

I'm getting "unable to process your claim due to tax ID- rendering NPI combination billed is not on file"

But this provider has approved claims with us under the same CPT code and is credentialed with Anthem , nothing else about the claim seems off.

I feel like i get so much trouble from anthem and when i call they can never give me more information.

Hello. Apologies if this is the wrong subreddit to post this question in, but I am wondering if anyone out there knows of online tools or databases that help identify preferred medication(s) and formularies for drugs that are administered in healthcare facilities and billed to medical benefits? Currently, I have to find each plan’s medical policy for a specific drug and wade through the documents to determine which agent(s) in a class the payer prefers. Given our payer mix, this is time consuming and not at all efficient. Any help is appreciated! Thanks.

We are a third party billing company who handles billing for numerous clients of different specialties and locations.

For charge entry we use a company overseas (outside the US) to handle the entry process. We started out with them using an excel sheet that had rules that were either specific to the client, to their location or rules that apply to all.

This document is now pushing 3000 rules, it has not been maintained properly and many of the rules are no longer valid.

Curious to know how other companies handle this type of process/document?

Would this be considered a complete ECRP or EGD?

Stent was removed and ampulla was identified but biliary and pancreatic duct cannulation was unsuccessful.

Does viewing the ampulla count as viewing a duct?

Hey everyone,

I'm reaching out for some thoughts and feedback on a concerning billing policy at a freestanding ER in Texas.

Background:

The ER initially waived ER copays during COVID-19. After the CARES Act ended, they continued waiving copays and marketed free visits to local schools. And by free, only bill out to insurance and not collect / bill copay , deductible or co insurance

Insurance companies subsequently stopped reimbursing and even held payments.

The ER briefly reinstated copay collection but then reduced it to a maximum of $220.

Now, they've reverted to essentially no copay collection and are pushing financial hardship waivers for all patients with copays or deductibles.

Patients do get a bill but after three, they stop sending them..

Concerns:

Sustainability: Is this billing model truly sustainable in the long term?

Ethics: While it may seem beneficial for patients, is it ethical to exploit loopholes and rely on financial hardship waivers?

Transparency: Is this approach transparent to patients and insurance companies? I'd appreciate any insights, experiences, or advice from the community.

Specific Questions:

How have other freestanding ERs handled similar situations?

What are the potential legal and ethical implications of this policy?

Could this approach lead to future reimbursement issues or audits?

Thanks in advance for your input!

So I was talking to my husband about my upcoming coding exam, whilst he was playing a role playing game with ChatGPT. He suggests, "why don't you ask the AI if it's familiar with CPT codes." Intrigued, I test it out and request the CPT code I use most often at my current job. It gives the correct one as well as the correct alternatives. I'm delighted! I say "neat! I'll use that at work for tough code situations!" So I resume making dinner. But then I begin to think to myself.. Hmmm.... if I can use chatGPt to code, so could my boss.... now really I don't see my current boss doing this, he's pretty old school. But it made me contemplate the future of medical coding and the value of my coding certification in a world where anyone needing the service could just use A.I. for wayyyyy cheaper. Granted it would be super expensive for small group practices like the one I work for to change all their EMR systems and switch to one that uses AI to analyze charts and then spit out a code, knowing the various payor subtleties and particularities. This is probably at least a decade away. But I've got at least 30 years left in the workforce!

Hmmmm.

Thoughts?

I work at a private practice therapist office and all of our providers are independently contracted. We have like 27 therapists. I’m actually the credentialing person but I’ve been working with the two billing people to try to get this fixed. For some reason UHC Medicaid and Dual Options keep paying this one clinician directly by check rather than paying the practice by EFT. Other UHC/Optum plans do not have this problem.

I literally can’t find an issue with her credentialing with Optum, UHC, or Medicaid. We have probably spent a total of 15 hours between us on the phone and live chat with UHC/Optum reps and departments just getting bounced around and getting no answers. They even reprocessed the claims and sent us a second check to the individual provider 😭😭

The claims we submitted are filled out the same way we filled out the claims for other providers who do not have this issue with this insurance.

Has anybody ever experienced something like this? If so, what was the cause and how did it get solved?

I bill for a specialist office in Arkansas with 4 providers. I have no formal billing training, I got fired from the front desk over a year ago and they had an open billing position. I'm winging it, but well enough that for all intents and purposes, I'm the supervisor.

I was "trained" from August to December, trainer quit. I was on my own for January to May. Hired a new person, they worked there until last month. Hired a new new person, they quit on Monday.

Due to the unfortunate staffing issues, I'm so behind on Medicaid that it's not funny. Like a whole year. All four of my providers accept it, and I'm spread so thin with literally everything else, I don't have time to submit through the portal, which take 15-20 minutes for crossovers.

Grand question is, what is the fastest way I can submit claims to Medicaid? Without hiring help, without having another employee help, no outsourcing, and absolutely no overtime?

Edit

Hey guys, I really appreciate all the help! But when I said I have no training and am wingin' it, I meant it.

"Can you not just do X?" My guy I didn't even know that was an option. Or how to even do it that way. All I know is paper or the portal.

Edit 2

You all have been a great help, but I've never felt so dumb. So thanks for that lol. I've figured a lot of things out on my own, but somethings have been left the way they were, and I haven't done anything with it, because I didn't know any better.

But I'd like to add some more info.

Our PM is Nextgen. We do electronic medical records. We do electronic claims. Everything that I hit submit on goes out at 6pm. We're also VERY paper based. I asked about and was told if we wanted to do it a different way, we would have to get a new PM. We typically get EFTs back, others pay through Zelis, credit cards, checks, direct deposit. Medicare sends a lot of the secondary claims out themselves. I don't know why it doesn't happen with Medicaid.

Our clearing house is Waystar. It's relatively new to us, it switched over in August-ish. I don't know a whole lot about it. I know we had to re-enroll for a lot of insurances.

I know the clinic is a sh*t show. I know we need the help. I will get a counterpart and that's most likely it. One of our providers isn't happy with way things are, and scheduled a management company to come out and evaluate. They did, and they would want an equal stake of the practice, the providers would each lose 5% and that was the last I heard of it. There was a single sentence suggestion of an outsource for just billing and that was also gone with the wind.

As for the couple people who have offered help, that's very nice of you. But that's not going to happen. Provider's get final say in everything and they aren't easily convinced of anything.

As for our office manager, she's definitely not married to a doctor. This is not her fault, or her doing whatsoever. You can dog the providers all you want, but not her. She's probably dealing with double or even triple what I'm dealing with. We're both in our 20's and it wasn't exactly planned for us to be in the situations we are now. We were thrown into the water with sharks, and then got some chum dumped on us, and the boat drove away yelling "You'll figure it out!" We're trying.

Yes, our turnover is incredibly high. It sucks. I know. It's stupidly high stress for more stupid reasons. We're also a specialist office and we treat a lot of cancer patients. Understandably, they aren't always in the best mood, and the staff of mostly under 30's seem like a good rage outlet I guess.

That being said, I do want to try to get things to run more smooth. I'm going to be contacting Nextgen and Waystar to see if I can get something going. I contacted the area rep who emailed me some nice manuals and information on setting up the electronic transmission.

I'm probably just going to link my manager the whole post and see how it goes from there. I really do appreciate yall.

My dad owns a small IT company (no employees) and services several private medical clinics in our area.

I work with him every now and then when he needs extra hands but nothing serious.

I finished my masters a couple months ago and have been looking for work since. Applying like a dog, interview here and there but no offers yet. My masters is in data analytics with a concentration in healthcare analytics.

My dad knows I'm struggling and asked me why don't I look into medical billing and automation since we have clients. He told me they pay 10-20k a month for that service.

I have a small coding background but nothing professional. Is this something doable?

Thank you.

Hello!

I have a long history of work in the hospitality industry. I'm 36 years old and I just can't do manual labor like I used to. I'm wanting to switch careers.

What does it take to become a medical biller and coder? I have no experience in the field, but have wanted to get into healthcare and have become discouraged as I have no idea where to start. I did get a certificate in health and wellness administration back in 2018, which was a dead end and did not result in landing a job as they wanted someone with hands on experience, which I did not have. Only the certification.

If I could get some insight on whether I should pursue this or not with no background in it, and what is needed and necessary to achieve a career in it, it would be greatly appreciated! I would hate to go back to school again only for it to result in more student debt and no career in what I'm seeking.

Thanks for reading!

I'm at a point in my life where I'm looking for a change of careers. I have an in as an inpatient medical coder at a hospital thanks to a friend in their HR department.

My first instinct was to research medical coding and how to get started in the industry. At a glance it seems like there are two governing organizations that regulate certifications, AHIMA and AACP, and respectively the entry level certs from these are CCA and CPC. What little I've read so far it seems like CCA focuses on inpatient coding and CPC focuses on outpatient coding. Since my potential entry into the industry would be as an inpatient coder, it makes sense to go for the CCA, along with my HR friend advising that they favor applicants with a CCA certification over a CPC certification.

So I go to AHIMA's website, look for their exam prep course and...that's where the issues start. After doing some research (and finding several posts about this on this subreddit) its become clear that AHIMA is not in a good state. Dozens of reports of botched user profiles, inability to schedule exams, inability to get exam results, inability to claim CEUs, etc. Personally, I've found their CCA exam prep bundle, which looks to be a blank product with no price, and adding it my cart and checking out seems to have done nothing, added nothing to my profile on their website and I'm kind of lost on what to do to move forward, which seems to line up with the complaints I've read here. Most concerning is the reports of lack of resolution or urgency around scheduling exams, getting results and claiming CEUs. Even if I manage to become knowledgeable enough to attend and pass the exam, if AHIMA is incapable of even scheduling it, administering results and upholding the very basics of their certification process...what is the outlook for new entrants into this industry?

Genuinely, how does somebody interested in joining this industry, as an inpatient coder for a hospital, actually go about achieving that goal? I've seen a lot of complaining here, a few recommendations of emailing the CEO or head of HR at AHIMA (which are bandaids, not solutions) but beyond that, I've gotten the vibe that certification via AHIMA is just not possible or advised at this point. Is the CIC, from AACP, simply the only recourse for somebody looking to break into the industry as an inpatient coder?

I am coming up on one year as a coder at the VA. I haven't had a good experience but I enjoy the work I do. I was wondering if any coders have a VISN they recommend that they have a good work environment/training. I'm hoping to transfer.

Trying to figure out if this industry cares about formal schooling through college or if something like Coursea is acceptable. Thoughts?

What if provider who did the service in Box 24J is not credentialed - Can I add the supervising provider in box 17?

When the claim decides to pay - are they pulling this from box 24J? Any info or links would be great!

I cannot find a concrete answer to this question. Does it need a modifier when billed with G0439? If so what is the modifier? And what diagnosis code can I use for this? There is alot of conflicting answers on the Family Medicine forum. Thanks in advance for your responses and time.

We had a mental health therapist stop by and ask if they can bill insurance for attending an IEP meeting at the patient’s school. I’m having a hard time locating information that says it’ll work. And if it will, what criteria needs to be met. Does anyone have any insight?

I've been tasked with restructuring our Insurance department. We have under 10 offices with ~20 doctors.

We have around 44% of our annual revenue sitting in aging claims (absurd, I know).

I'm considering outsourcing our billing - primarily because finding skilled billing specialists seems to be very difficult.

Anyone have insight on this decision? Pros/cons of outsourcing vs in house?

I billed an annual wellness visit and depression screen G0439 + G0444 to Priority Medicare Advantage. I included Z90.710 for acquired absence of uterus and cervix since she is s/p TAH to close the pap gap. But now Priority is denying saying that it needs an anatomical modifier but I don't know what would be appropriate for a TAH since it's neither lateral nor bilateral.

Hello everyone!

I do the insurance claims and billing for a solo mental health care private practice. We have a client with BCBS insurance. This client has been seen bi-weekly the entire year. All claims had been paid by BCBS throughout the year with no issues.

Recently, they sent us an explanation of payment showing that they had determined that the first 7 claims of the year were "overpayments" with the remark code of "N4."

The N4 error code reads "Missing/Incomplete/Invalid prior Insurance Carrier(s) EOB." Not sure what this could mean, the other payments from the year have paid as normal with the same information and they accepted and paid the claims.

They have applied a negative balance for those seven appointments now that we are going to have to pay back over time through other BCBS sessions.

My first questions is: Does anyone have any experience with a similar situation?

Secondly: I am having an awful time trying to find some contact information with BCBS to speak with someone about this. We are a fairly new private practice and have not experienced this before.

Thanks so much for reading!

My friend had a surgery procedure that was ~$12K total. Was supposed to be $6K upfront out of pocket and $6K for "insurance portion of surgery.". She paid the upfront portion, and had the surgery, which went well. This was now 2 years ago.

Of the remaining $6K, her insurer, Blue Cross, denied significant portions of the itemized claims, saying "THIS AMOUNT EXCEEDS THE MAXIMUM ALLOWABLEAMOUNT FOR THIS SERVICE." in some instances and that because multiple surgical procedures happened on the same day, the major procedure is billable at 100% but the rest at 50%.

The surgery provider is about to send the outstanding debt (around $5K) to collections. Does my friend have ground to stand on to deny paying because Blue Cross denied most the claims?

Hey guys, is reimbursement cut down to 85% of the 80% for non providers billing HCPCS level II codes (product codes, example A/q codes) in the private office?

I knew the CPT code for applying the product would be 15275… but wasn’t expecting the products reimbursement itself to be. I thought the asp payment would be the same…

Hi I'm thinking about starting a medical billing company, but I'm at a loss when it comes to software. Right now, I plan on doing everything individually in the each clients EHR, but what about if I get more customers? I want to be able to handle everyone's billing in one place, on one software, while still letting each client handle their patients/scheduling through their own preferred EHR. Are there any options to do this?

Like is there a software or product that would let me integrate with their EHRs and I could do just the billing in my system while they do clinical stuff in theirs. And the 2 systems would talk to each other and autoupdate each other's info, like posted payments. I realize I might be asking for magic right now, but I figured I'd try. Seems like the clearinghouse rcm products might work (I think?), but they seem pretty expensive. Maybe something like EZClaim can do this but I'm not sure, the articles I read weren't clear to me. Thank you for any input